ETSU Campus Recreation follows the Aerobics and Fitness Association of America (AFAA) Guidelines - A Guide to Personal Fitness Training 2015
ETSU CAMPUS RECREATION - PERSONAL TRAINING REGISTRATION PACKET
Please return this packet, with all 4 pages fully completed and signed to the BCPA Member Services desk.
Name:_________________________________________________________________________
Address:_______________________________________________________________________
Phone Number (s): Cell: _________________________Other: _____________________________
E-mail address:__________________________________ E #:_________________________
I am: _____Student
_____ Faculty/Staff
_____Spouse/Domestic Partner
_____Dependent (16 & older)
Are you signing up for buddy training? If so, please list your buddy’s name_________________________
The buddy MUST also fill out his or her own Personal Training Request Packet.
I (We) am (are) signing up for: _______Two free sessions ______Four 1 hour sessions ______ Eight 1 hour
sessions
Training sessions offered are either individual or buddy sessions. Clients must identify their own buddy,
Campus Recreation cannot assign buddies. To receive the most benefit, clients who wish to train with buddy
sessions need to have similar fitness goals which allow the trainer to focus on applying similar fitness
programming to both clients.
All ETSU students, faculty/staff and retirees receive two complimentary 1 hour personal training sessions* in a
lifetime. Spouse, domestic partner and dependent members are not eligible for the two complimentary sessions
(but are eligible to purchase a training package). This form must be filled out for the two complimentary
sessions or to purchase a personal training package. After the two complimentary sessions, patrons may
purchase one of the following packages. All package fees are to be paid at the CPA Member Services desk with
cash, check or EBUCS.
Student
4 Sessions
Single Sessions
$50
Buddy Sessions
$80
8 Sessions
$90
$140
Faculty/Staff/SDPD
Single Sessions
Buddy Sessions
4 Sessions
8 Sessions
$60
$110
$100
$150
The two complimentary sessions are a one-time only concession. All PT sessions must be used within a year of
purchase. Any remaining sessions after 12 months will be forfeited. Any cancellations without 24 hour notice
will result in one session being charged. If you are buddy training and your buddy does not show, you will still
be charged for one buddy session.
*Single and buddy sessions can be offered in either 8 or 16 half-hour sessions. Please check here if you wish to
have your 1 hour sessions broken into 30 minute sessions:
NOTE: Depending on the current wait list for a trainer, it could be up to 10 business days
or more before you will be contacted to set up your training sessions. If it has been longer,
than 10 business days, please email fitness@etsu.edu.
PHYSICAL ACTIVITY READINESS QUESTIONNAIRE (PARQ)
1. Has your doctor ever said that you have a heart condition/high blood pressure?
Yes_____ No_____
2. Do you feel pain in your chest during or after physical activity?
Yes_____ No_____
3. Do you lose your balance because of dizziness or do you ever lose consciousness?
Yes_____ No_____
4. Do experience unusual fatigue or shortness of breath at rest or with mild exertion?
Yes_____ No_____
5. Do you have a bone or joint problem that could be worse by a change in your physical activity?
Yes_____ No_____
6. Do you know of any other reason you should not do physical activity?
Yes_____ No_____
MEDICAL HISTORY QUESTIONNAIRE (please use additional paper if necessary)
1. When was the last time you had a physical examination?
2. List any medications you are taking, why, and the dosage level if known.
3. Has your doctor ever diagnosed you as having asthma, heart disease, stroke, diabetes, or epilepsy? Has
anyone in your family been diagnosed with any of these conditions?
4. Have you ever had back problems, arthritis, or orthopedic problems?
5. FEMALES ONLY: Are you pregnant, or do you have any reason to believe you are?
6. Have you had surgery that will limit your exercise program? If yes, please explain.
7. Do you have an at-risk cholesterol reading?
Yes_____
No_____
Not available_____
8. Do you have an abnormal resting ECG?
Yes_____
No_____
Not available_____
9. How often do you consume alcoholic beverages?
a) 0 times per week
b) 1-2 times per week
c) 2-3 times per week
d) 3+ times per week
10. What is your current age? ________
11. On a scale of 1 (least intense) to 10 (most intense), how would you like your training to be structured? ____
12. Have you ever participated in a regular exercise routine?_________________________________________
***Doctor’s clearance may be required to begin Personal Training sessions.***
TRAINING AVAILIBILITY
Per day, please list the times you are available to train.
Monday:____________________________ Tuesday:________________________________
Wednesday:_________________________ Thursday:_______________________________
Friday:_____________________________ Saturday:_________________ Sunday:_________________
Please use this space to write anything else you would like your trainer to know:
Campus Recreation Agreement and Release of Liability
1.
In consideration of being allowed to participate in the activities and programs of East Tennessee State University
Campus Recreation and to use its facilities, equipment and machinery, in addition to East Tennessee State
University Campus Recreation payment of any fee or charge, I do hereby waive, release and forever discharge its
directors, officers, agents, employees, representatives, successors, and assigns, administrators executors, and all
others from any and all responsibilities or liability from injuries or damages resulting from any participation in
any activities or my use of equipment or machinery in the above mentioned activities. I do also hereby release all
those and any others acting upon their behalf from any responsibility or liability for any injury or damage to
myself, including those caused by the negligent act or omission of any of those mentioned or others acting on
their behalf or in any way arising out of connect with my participation in any activities of personal training at East
Tennessee State University Campus Recreation or the use of any equipment at East Tennessee State University
Campus Recreation.
IF YOU UNDERSTAND AND AGREE, PLEASE INITIAL_______________
2.
I understand and am aware that strength and flexibility and aerobic exercise, including the use of equipment, are a
potentially hazardous activity. I also understand that fitness activities involve the risk of injury and even death,
and that I am voluntarily participating in these activities and using equipment and machinery with knowledge of
the dangers involved. I hereby agree to expressly assume and accept any and all risk of injuries or death.
IF YOU UNDERSTAND AND AGREE, PLEASE INITIAL_________
3.
I do hereby further declare myself to be physically sound and suffering from no condition, impairment, disease,
infirmity, or other illness that would prevent my participation or use of equipment or machinery except as
hereinafter stated. I do hereby acknowledge that I have been informed of the need for a physician’s approval for
my participation in any exercise/fitness activity or in the use of any equipment and machinery. I also acknowledge
that it has been recommended that I have a yearly or more frequent physical examination and consultation with
my physician as to physical activity, exercise and use of exercise and training equipment so that I might have
these recommendations concerning these fitness activities and equipment use. I acknowledge that I have either
had a physical examination and have been given my physician’s permission to participate, or that I have decided
to participate in activity and use of equipment and machinery without the approval of my physician and do hereby
assume all responsibility for my participation and activities, and utilization of equipment and machinery in my
activities.
IF YOU UNDERSTAND AND AGREE, PLEASE INITIAL_______________.
Express Assumption of Risk for Participation in Specified Activity
The undersigned, hereby expressly and affirmatively state that I wish to participate in the Personal Training
Program at East Tennessee State University Campus Recreation. I realize that my participation in this activity
involves risk of injury, including but not to limited to soreness, muscular joint injury, abnormal blood pressure,
fainting, disorders of heart beat, cardiac events and even the possibility of death. I also recognize that there are
many other risks of injury, including serious disabling injuries, which may arise due to my participation in this
activity and that it is not possible to specifically list each and every individual injury risk. However, knowing
the material risk and appreciating, knowing and reasonably anticipating that other injuries and even death are a
possibility, I hereby expressly assume all of the delineated risk of injury, all other possible risk of injury and
even death which could occur by reason of my participation.
I have the opportunity to ask questions. Any questions, which I have asked, have been answered to my
complete satisfaction. I subjectively understand the risk of my participation in this activity, and knowing and
appreciating these risks I voluntarily choose to participate, assuming all the risk of injury or even death due to
my participation.
______________________________________________
PARTICIPANT PRINT NAME
__________________________________________ ______________
PARTICIPANT SIGNATURE
DATE